Monday, May 25, 2015

STUDI KASUS D



CASE IV
A.                      Patient Description
  • Name               : MYPM 
  •  Age                 : 59 years 
  • Reg. No           : 552069
  • Gender             : Male 
  • Admission       : 13/10/06 
  • Weight : 104 kg (IBW=66.1) 
  • Race                 : Malay
  •  Heights           : 170 cm

B.            Chief Complaint (CC)
               Chest pain: +severe, typical, Left arm numbness for 1 day
               + Sweating
               + Nausea
C.           History of present illness (HPI)
Ÿ Known history of IHD (3 vessel disease with occluded SVE)
Ÿ Planned for PCI in December 2006
Ÿ On 16/2/06, NYHA I-II, TIMI score 4/7
Ÿ CABGs were done on 1986 & 1995

D.           Family & Social History  
n  Father and mother has history of Ischemic heart disease and Diabetes Mellitus.
n  Staying with family member.
n  None smoker or alcoholic user
n  Pensioner from Penang Hospital as attendant.  

E.           Medical History Interview


HEART PROBLEMS:

URINARY/REPRODUCTIVE:

Chest pain (angina)
ü
Urinary or bladder infection

Past heart attack
ü
Prostate problems

Heart failure

Hysterectomy

Irregular heartbeat

Chronic yeast infections

Heart by-pass surgery
ü
Kidney disease

Rheumatic fever

Dialysis

Other:

Other:

EYES, EARS, NOSE & THROAT

MUSCLES AND BONES

Poor vision

Arthritis

Poor hearing

Gout

Glaucoma

Back pain

Sinus problem

Amputation

Bladder disorder

Joint replacement

Other:

Other:

GASTROINTESTINAL

NEUROLOGICAL

Heartburn

Headache

Ulcer

Seizures or epilepsy

Constipation

Parkinson’s disease

Diverticulitis

Dizziness

Liver disease

Past stroke

Gallbladder problems

Fainting

Pancreatitis

Depression

Other:

Anxiety



Other:

DO YOU HAVE:

LUNG PROBLEMS

High blood pressure
ü
Asthma

Low blood pressure

Emphysema

High cholesterol
ü
Bronchitis

Diabetes
ü
Other:

Cancer



Anaemia



Bleeding disorder

DO YOU HAVE OR USE…?

Hay fever

Glasses

Sleeping problems

Hearing aid

Other:

Other:

DO YOU HAVE A FAMILY HISTORY OF:
High blood pressure



Heart disease
ü
Other:Stroke

Diabetes
ü




F.S.1

Current Prescription Medication Regimen
Name/Dose/Strength/Route
Schedule/
Frequency of Use
Indication
Start Date (and stop date if applicable)
Prescriber
Indication issues, effectiveness, safety, compliance and cost
T. Aspirin 150mg
OD
Antiplatelet
Con’t


T. Metoprolol 100mg
BD
Hypertention/IHD
Con’t


T. Isorsobide Dinitrate 10mg
TDS
IHD
Con’t


T. Vastarel 20mg
TDS
IHD
Con’t


T. Valsartan 80mg
OD
Hypertension/IHD
Con’t


T. Simvastatin 10mg
OD
Dyslipidaemia
Con’t


T. Metformin 1g
BD
Diabetes mellitus
Con’t


T. Gliclazide 80mg
OD
Diabetes mellitus
Con’t








F.S.2
Current Nonprescription Medication Regimen (OTC, herbal, homeopathic, nutritional, etc)
Name/Dose/Strength/Route
Schedule/
Frequency of Use
Indication
Start Date (and stop date if applicable)
Prescriber
Indication issues, effectiveness, safety, compliance and cost
Nil

















F. Allergies:
History of allergies:     Yes [  ]                No known allergies [ü]
Are you allergic to any prescription drugs, over-the-counter medication, herbals or food supplements?If yes, please list the medications and type of allergic reaction experienced:_______________


Are there any medications that you are not allergic but cannot tolerate?

[  ]Yes    [ü] No    If yes, please list the medications and the reaction experienced:
                                                                                   
 



What environmental allergies do you have?           Nil

 


G.  Medication Compliance assessment
Base questions on history obtained to this point.
Your medication regimen sounds complex and must be hard to follow;

How often would you estimate that you miss a dose?
Seldom

Everyone has problems with following a medication regimen exactly as written.
What are the problems you are having with your regimen?
Claimed tolerate well by patient.
Compliance rate: Compliant [ü ]    Moderate/partial compliant [  ]    Noncompliant [  ]



H. Social History
            Smoking                      : Ex-smoker
            Alcohol                       : Non alcoholic user
            Other drug use            : -
            Caffeine intake           : 3 cups (≈100ml) per week

Diet
Routine Exercise/Recreation
Daily Activities/Timing
Low salt – moderate compliance
Daily brisk walking
Routine exercise, mild to moderate daily activities.
Low fat diet


Diabetic diet – compliance



J. Physical examination / laboratory for initial and follow-up.
Date
13/10/06
Date
13/10/06
Height(cm)
170 cm
Na+ (mmol/L)
137
Weight(kg)
104 kg
K+ (mmol/L)
4.1
Temp(C°)
37.0
BUN (mmol/L)
6.4
BP(mmHg)
147/86
Creatinine (umol/L)
105
Pulse(bpm)
82
Urine output
-
RR/VENT
20
I/O
-
Peak Flow
-
Uric acid/Mg (mmol/L)
-
pH
-
Ca2+ (mmol/L)
-
SPO2
-
PO4 (mmol/L)
-
PCO2
-
FBS (mmol/L)
8.7 (17/10/06)
HCO
-
BMI
36
LDL (mmol/L)
1.8 (19/9/06)
LDH (U/L)
164
HDL (mmol/L)
0.9 (19/9/06)
CK (U/L)
87
TG (mmol/L)
2.1 (19/9/06)
INR
1.1
T.Chol (mmol/L)
3.7 (19/9/06)
PT/aPTT
12.8/25.4
WBC (x103/uL)
8.3
TT/FDP

Hgb (g/dL)
13.9
Total Bili (umol/L)
12
Platelet (x103/uL)
234
Hct
41.9


ALT/AST (U/L)
ALT:73 ; AST:49


Alk Phos (g/L)
61
X-ray

Total Protein (g/L)
Albumin (g/L)
71
40
Echocardio
EF 33% (15/10/06)
TSH
-
ECG
Lead I, II Q wave
HbA1c (6.8-8.6)-Fair control
>8.6%- Poor control
8.6% (17/10/06)

Pharmalogic review of system:
General: Alert, conscious, chest pain, left arm numbness, +sweating
Vital Signs: BP 147/86 mmHg ; PR 82bpm ; T 37.0 °C ;
KUT: -
HEPATIC: No hepatomegaly
CVS: DRNM
CHEST: Lungs clear
BLOOD: WNL
ABDO: Soft, non tender, no organomegaly
SKIN/MUSCLE: -
NEURO/MENTAL: -
HEENT: -
K. Physical Examination/ Daily Progress (D1-D4)

13/10/06
14/10/06
15/10/06
16/10/06
General
Alert, conscious, complaint of chest pain (severe, typical), left arm numbness, +sweating, +Nausea
Still complaint of chest pain, left sided, no shortness of breath
Alert, conscious, no more chest pain
Comfortable，afebrile
Vital Sign




BP (mmHg)
147/86
126/80
137/87
157/71
Pulse (bpm)
82
61
68
65
Temp (oC)
37.0
37.0
37.0
37.0
CVS
DRNM
DRNM
DRNM
S1S2
Lungs
Clear
Clear
Clear
Clear
ECG
Q wave at lead I, II
No ischemic changes
-
--
Physician Plan
1.       T. Plavix 300mg stat, then 75mg OD
2.       S/L T. GTN 1/1 stat
3.       IV Morphine 2.5mg stat
4.       IV Metoclopromide 10mg stat
5.       SC Clexane (Enoxaparin) 80mg stat & BD x 3/7 Patient refuse sc Clexane
6.       Change to IV Heparin bolus 5000 U, then 1000U infusion/hour
7.       NP O2 3L/min
1.       ↑IV Heparin to 1200U/hour and review APTT
2.       ↑T. Gliclazide 160mg BD
3.       ↑IV Heparin to 1300U/hour (11.55pm)
4.       Start IV Isoket 1mg/hour & inform if BP<100/60 (11.55pm)
1.       Off IV Isoket
2.       Off Nasal Prong
3.       Continue Hepatin & keep INR 1.5-2.5 (should be APTT not INR, written by houseman)
1.       ↑ IV Heparin to 1600U/hour
2.       ↑ T. Isosorbide dinitrate 20mg TDS
3.       Add Gemfibrozil 300mg BD
4.       Plan PCI (LAD) in December





K. Physical Examination/ Daily Progress (D5-D6)

17/10/06
18/10/06
General
Afebrile, comfortable
+ chest pain, afebrile
Vital Sign


BP (mmHg)
132/68
113/68
Pulse (bpm)
62
83
Temp (oC)
37.0
37.0
CVS
S1S2, DRNM
S1S2
Lungs
Clear
Clear
ECG
-
-
Physician Plan
1.       ↑ IV Heparin to 1800U/hour
2.       Continue others
3.       Check APTT on 12 noon
1.       ↑ IV Heparin to 2000U/hour
2.       Off Heparin
3.       PCI on 11/12/06
4.       Discharge patient today


L. Laboratory findings and follow up:

13/10/06
15:53
13/10/06
21:56
14/10/06
10:49
14/10/06
19:39
15/10/06
08:40
15/10/06
22:11
16/10/06
17:31
17/10/06
08:55
17/10/06
14:57
PT
11.5-13.5 sec
12.8
13.4
13.4
12.7
12.7
13.7
13.0
13.0
12.9
INR
0.8-1.2
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.1
1.1
APTT
24.0-35.0 sec
25.4
34.8
25.3
30.7
28.0
31.0
43.8
61.6
41.2
Action

Baseline
Start IV Heparin

↑ IV Heparin to 1300U/hour
↑ IV Heparin to 1400U/hour

↑ IV Heparin to 1600U/hour
↑ IV Heparin to 1800U/hour



L. Laboratory findings and follow up:
Test
Normal Range
13/10/06
14/10/06
15/10/06
16/10/06
17/10/06
18/10/06
WBC
5.2-12.4 x 10^3/uL
8.3
-
-
-
-
-
RBC
4.2-5.4 x 10^6/uL
4.6
-
-
-
-
-
HGB
12 -16  g/dL
13.9
-
-
-
-
-
HCT
37 – 47  %
41.9
-
-
-
-
-
MCV
81 – 99  fL
91.9
-
-
-
-
-
MCHC
33 – 37  g/dL
33.2
-
-
-
-
-
PLT
130 – 400  10^3/uL
234
-
-
-
-
-



-
-
-
-
-
Na+
135-145 mmol/L
137
-
-
-
-
-
K+
3.5-5.0 mmol/L
4.1
-
-
-
-
-
Urea
1.7-8.3 mmol/L
6.4
-
-
-
-
-
Creat
57-130 umol/L
105
-
-
-
-
-
Cl-
86-108
101
-
-
-
-
-
CLcr
75-125ml/min
62.61
-
-
-
-
-



-
-
-
-
-
T Pro
66-87g/L
71
-
-
-
-
-
Alb
35-52 g/l
40
-
-
-
-
-
Glb
23-35 g/l
31
-
-
-
-
-
A/G
0.9-1.8
1.3
-
-
-
-
-
T Bili
0-24mmol/l
12
-
-
-
-
-
ALT
0-42 U/l
73
-
-
-
-
-
ALP
34-104 g/l
61
-
-
-
-
-



-
-
-
-
-
AST
0-37 U/L
38
49
46
-
-
-
CK
24-195 U/L
87
67
71
-
-
-
LDH
135-225 U/L
164
168
205
-
-
-



-
-
-
-
-
T Chol
<5.2 mmol/L
3.7 (19/9)
-
-
-
-
-
TG
<1.8 mmol/L
2.1 (19/9)
-
-
-
-
-
LDL
<3.36 mmol/L
1.8 (19/9)
-
-
-
-
-
HDL
>1.29 mmol/L
0.9 (19/9)
-
-
-
-
-
%HDL-Chol
15-25
24 (19/9)
-
-
-
-
-



-
-
-
-
-
Reflomet
mmol/L

-
-
8.2
8.9
9.4
FBG
mmol/L

-
-
-
8.7
-
HbA1c
6.8-8.6%-Fair control
>8.6%-Poor control
-
-
-
8.6
-


K .Diagnoses/Provisional Dx / Acute / Chronic medical Problems

[1] Unstable Angina
[2] Hypertension
[3] Type II Diabetes Mellitus
[4] Ischemic Heart Disease (COROS showed 3VD)

 L. Drug treatment in the ward
Current Drug Therapy (Oral, Parenteral, Inhaler and others)
Drug Name/ Dose/ Strength /Route
Schedule
Duration
Indication


Start
Stop

T. Aspirin 150mg
OD
cont
cont

T. Metoprolol 100mg
BD
cont
cont

T.Isorsobide Dinitrate 10mg
TDS
cont
16/10/06

T.Isorsobide Dinitrate 20mg
TDS
16/10/06
cont

SL GTN 1/1
STAT
13/10/06
13/10/06

IV Morphine 2.5mg
STAT
13/10/06
13/10/06

IV Metoclopromide 10mg
STAT
13/10/06
13/10/06

T. Vastarel 20mg
TDS
cont
cont

T. Valsartan 80mg
OD
cont
cont

T. Simvastatin 10mg
ON
cont
cont

T. Metformin 1g
BD
cont
cont

T. Gliclazide 80mg
OD
cont
14/10/06

T. Gliclazide 160mg
BD
14/10/06
cont

T. Plavix 300mg stat & 75mg
OD
13/10/06
cont

C. Gemfibrozil 300mg
BD
16/10/06
cont

IV Isoket 1mg/hr
Infusion
14/10/06
15/10/06

IV Heparin 5000U Bolus, then 1000U/hr
Infusion
13/10/06
14/10/06

IV Heparin 1200U/hr
Infusion
14/10/06
14/10/06

IV Heparin 1300U/hr
Infusion
14/10/06
16/10/06

IV Heparin 1600U/hr
Infusion
16/10/06
17/10/06

IV Heparin 1800U/hr
Infusion
17/10/06
18/10/06



Posted by at

No comments:

Post a Comment

Subscribe to: Post Comments (Atom)